The Road to Endeavour:
Development and Evaluation of a Programme for Those Presenting with
Repeated Self-Harm and Chronic Suicidality
Daniel Flynn, Principal Psychology Manager, Cork South Mental Health Services
Mary Kells, Senior Clinical Psychologist, North Lee Adult Mental Health Services
Introduction
It is estimated that 11-20% of attendees to mental health services have a
co-morbid diagnosis of Borderline Personality Disorder (A Vision for Change,
2006). Borderline Personality Disorder (BPD) is marked by emotional,
behavioural and impulse dyscontrol; unstable interpersonal relations; and high
levels of suicidal behaviour (DSM-IV-TR, 2000).
Dialectical Behaviour Therapy (DBT) has been shown to be efficacious in
treating BPD (Kliem et al., 2010). ‘A Vision for Change’ (a report of the expert
group on mental health policy in Ireland) suggests that each area in the Health
Service Executive (HSE) should develop an agreed policy on the management of
service users with BPD. The report suggests the creation of a dedicated DBT
team, where individuals committed to developing this specialist service be
seconded for weekly sessions from their sector Community Mental Health Teams
(A Vision for Change, 2006).
In line with these recommendations, North Lee Adult Mental Health
Services established ‘The Endeavour Programme’ in 2010. ‘The Endeavour
Programme’ is a 12 month DBT talking treatment which focuses on learning
principles. It balances acceptance and change, and is principle rather than
protocol driven. There are a number of components including:
•
Group Skills Training
•
Individual therapy
•
Phone Coaching
•
Consultation team meeting
Endeavour – a dictionary
This study examines the effectiveness of this pilot
programme in year one of its implementation.
definition
An earnest attempt to achieve
something
An enterprise or directed
activity.
Method
The non-parametric Wilcoxon Signed Ranks test was then used to
identify statistically significant differences in the measures across the
four time points. A statistically significant decrease was found between
Time 1 (Pre) and Time 2 (6 months) in depression (z = -2.81, p < .01)
hopelessness (z = -2.36, p < .05) and suicidal behaviour (z = -2.53, p <
.01). The decrease in borderline symptoms approached significance (z =
-1.72, p = .09). An increase in quality of life was observed, although it
wasn’t found to be statistically significant.
A statistically significant decrease was also observed from Time 1
(Pre) to Time 3 (Post) for depression (z = -2.94, p < .01), hopelessness
(z =
-2.38, p < .05), suicidal behaviours (z = -2.67, p < .01) and
borderline symptoms (z = -2.66, p < .01). An increase in quality of life
was observed, although again, was not statistically significant.
As there were a very small number of participants for the 6 month
follow-up data (n=6), it is not possible to statistically analyse the followup data. However, as can be observed in figure 1, scores on all five
measures for time 4 (6 month follow-up) were maintained and remained
similar to those observed at time 3.
Frequency of service utilisation was then examined for participants
before, during and after the DBT programme. This was done by
identifying the number of emergency department visits, inpatient
admissions and number of bed days for the 12 participants for the
following timeframes (12 months prior to programme, 12 months during
programme, and 6 weeks following programme completion). The results
are presented in table 1.
Table 1. Hospitalisation days for 12 participants in the DBT Programme
• There were 12 participants who had a primary
diagnosis of BPD and were attending
North Lee Adult Mental Health Services.
Emergency
Dept Visits
• Effectiveness was evaluated by administering
a number of measures to participants at
four time points: baseline (prior to programme
commencement); 6 months during programme; end of programme
(12 months); and at 6 month follow-up. The measures examined:
•
•
•
•
•
Borderline Symptoms (BSL-23; Bohus et al., 2007)
Suicidal Behaviour (BSL-23 Sup.; Bohus et al., 2007)
Depression (Beck Depression Inventory- Second Ed.; Beck, 1996)
Hopelessness (Beck Hopelessness Scale; Beck, Weissman, Lester
& Trexler, 1974)
Quality of Life (WHO; 1993)
• Frequency of service utilisation (inpatient admission and emergency
department visits) was also examined.
Results
120
Median (n=12)
100
80
60
40
20
0
6 months
Depression
Suicidal Behaviour
Quality of Life
Bed Days
Used
Cost*
*
During DBT
6 weeks
post DBT
49
6
0
12
3
1
207
45
1
€144,900
€31,500
€700
Cost in bed days at conservative cost of €700.00 per person per night
It can be seen in table 1 that there was a significant reduction in the
number of emergency department visits, inpatient admissions and bed
days in the 12 months prior to participation in the DBT programme,
compared to during and 6 weeks following programme completion.
Conclusions and Implications
The data was first explored using descriptive statistics to examine results
of outcome measures over time. Figure 1 presents the median values for the
five measures observed across an 18 month period.
Pre
Admissions to
Psychiatric
Unit
12 months
before DBT
Post
6 month follow-up
Borderline Symptoms
Hopelessness
Figure 1. Median Values for Borderline Symptoms, Suicidal Behaviour,
Depression, Hopelessness and Quality of Life at four time points
From the results, it can be seen that DBT was associated with
improved outcomes in an Irish context. There were significant reductions
in outcome measures (depression, hopelessness and borderline
symptoms) over time. An increase in quality of life was also observed.
Significant reductions were also found in the frequency of service
utilisation following completion of the DBT programme.
Following on from Year 1 of the pilot project, additional funding
from the National Office for Suicide Prevention (Ireland) has been used
to expand the programme across Integrated Services Areas in Cork.
Funding has also recently been allocated to evaluate a national project
which evaluates the implementation of DBT programmes across Ireland.
Recommendations for future research include:
• comparing DBT with a control group in an Irish context
• establishing if having significant others participate in systemic
interventions has additional benefits for the service user.
Endeavour Programme, North Lee Adult Mental Health Services, HSE South, Inniscarraig House, Western Rd., Cork
danielm.flynn@hse.ie
Research supported by funding from the National Office for Suicide Prevention
mary.kells@hse